simulation lab: practical applications for tissue re ... · olympus america inc., karl storz...

AAGL acknowledges that it has received support in part by educational grants and equipment (in-kind) from the following companies:

3-Dmed, CONMED Corporation, CooperSurgical, Covidien, Ethicon US, LLC, Olympus America Inc., Karl Storz Endoscopy-America, Inc., Symmetry Surgical

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Simulation Lab:

Practical Applications for Tissue Re-approximation,

Knot Tying and Suturing Technologies

PROGRAM CHAIRS

Jin Hee (Jeannie) Kim, MD & Nash S. Moawad, MD, MS

Krisztina I. Bajzak, MD, MSLydia E. Garcia, MD

Kimberly A. Swan, MD

Mandi L. Beman, MDSusan Khalil, MD

Mireille Truong, MDJohnny Yi, MD

Amy Broach, MDJessica M.B. Ritch, MDBich-Van T. Tran, MD

GLOBAL CONGRESSON MINIMALLY INVASIVE GYNECOLOGYNOV. 17-21, 2014 | Vancouver, British Columbia

43rd AAGL

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description (SUTR‐700) ..................................................................................................................... 1 Course Description (SUTR‐701) ..................................................................................................................... 2 Disclosure ...................................................................................................................................................... 3 Handling Suture and Needle, Intra‐Corporeal Knot Tying N.S. Moawad ................................................................................................................................................. 4 Improve Efficiency and Avoid Errors N.S. Moawad ................................................................................................................................................. 9 Extra‐Corporeal Knot Tying J.H. Kim ........................................................................................................................................................ 13 Suture Types and Characteristics; Suturing Devices J.H. Kim ........................................................................................................................................................ 16 Cultural and Linguistics Competency ......................................................................................................... 22

SUTR-‐700 Simulation Lab: Practical Applications for Tissue Re-‐approximation, Knot Tying and Suturing

Technologies

Jin Hee (Jeannie) Kim, Chair Nash S. Moawad, Co-‐Chair

Faculty: Krisztina I. Bajzak, Mandi L. Beman, Amy Broach, Lydia Garcia, Susan Khalil, Jessica M.B. Ritch,

Kimberly A. Swan, Mireille Truong, Bich-‐Van T. Tran, Johnny Yi This course will provide an introduction to basic and advanced laparoscopic suturing techniques in a dry lab setting and is designed for participants wanting to expand their laparoscopic suturing skills. This course will present a variety of techniques for needle loading and tissue re-‐approximation from different port configurations in laparoscopic box trainers. Techniques and clinical applications for extra-‐corporeal, intra-‐corporeal knot tying, and running suturing techniques relevant to vaginal cuff closure, myomectomy, and cystotomy repair will be presented. In addition, various applications of different suture materials and alternative suturing devices and technologies utilized in gynecologic laparoscopy will be reviewed. This course will aim to present the material in a systematic fashion with concrete and focused objectives throughout the session. Faculty will provide an interactive environment to meet the needs of the individual, critical to effective learning. This course is designed for the practical gynecologist to help determine which suturing techniques will work best in his or her surgical practice. This course is designed to help improve suturing skills for immediate clinical application. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Explain how to overcome the obstacles to laparoscopic suturing and knot tying in relation to depth perception and port placement; 2) reproduce efficient techniques for laparoscopic tissue re-‐approximation, suture management, and running closures; 3) Recognize and perform efficient intra-‐corporeal and extra-‐corporeal knot tying, the common mistakes encountered, and how to correct them; and 4) compare and distinguish potential benefits of suturing technologies and devices used in laparoscopy.

Course Outline 7:00 Welcome, Introductions and Course Overview J.H. Kim 7:05 Pre-‐Test (3 minutes) All Faculty 7:20 Handling Suture and Needle, Intra-‐Corporeal Knot Tying N.S. Moawad 7:35 LAB I: Drills, Needle Loading, Intra-‐Corporeal Knot Tying All Faculty 8:05 Improve Efficiency and Avoid Errors N.S. Moawad 8:20 LAB II: Continuous Suturing, Advanced Skills All Faculty 8:50 Questions & Answers All Faculty 9:00 Break 9:15 Extra-‐Corporeal Knot Tying J.H. Kim 9:25 LAB III: Extra-‐Corporeal Knot Tying All Faculty 9:50 Suture Types and Characteristics; Suturing Devices J.H. Kim 10:05 Post-‐Test All Faculty 10:20 LAB IV: Troubleshooting, Supra-‐Pubic Approach, Barbed Suture and Suturing Devices All Faculty 10:50 Questions & Answers All Faculty 11:00 Adjourn

Page 1

SUTR-‐701 Simulation Lab: Practical Applications for Tissue Re-‐approximation, Knot Tying and Suturing

Technologies

Nash S. Moawad, Chair Jin Hee (Jeannie) Kim, Co-‐Chair

Faculty: Krisztina I. Bajzak, Mandi L. Beman, Amy Broach, Lydia Garcia, Susan Khalil, Jessica M.B. Ritch,

Kimberly A. Swan, Mireille Truong, Bich-‐Van T. Tran, Johnny Yi This course will provide an introduction to basic and advanced laparoscopic suturing techniques in a dry lab setting and is designed for participants wanting to expand their laparoscopic suturing skills. This course will present a variety of techniques for needle loading and tissue re-‐approximation from different port configurations in laparoscopic box trainers. Techniques and clinical applications for extra-‐corporeal, intra-‐corporeal knot tying, and running suturing techniques relevant to vaginal cuff closure, myomectomy, and cystotomy repair will be presented. In addition, various applications of different suture materials and alternative suturing devices and technologies utilized in gynecologic laparoscopy will be reviewed. This course will aim to present the material in a systematic fashion with concrete and focused objectives throughout the session. Faculty will provide an interactive environment to meet the needs of the individual, critical to effective learning. This course is designed for the practical gynecologist to help determine which suturing techniques will work best in his or her surgical practice. This course is designed to help improve suturing skills for immediate clinical application. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Explain how to overcome the obstacles to laparoscopic suturing and knot tying in relation to depth perception and port placement; 2) reproduce efficient techniques for laparoscopic tissue re-‐approximation, suture management, and running closures; 3) Recognize and perform efficient intra-‐corporeal and extra-‐corporeal knot tying, the common mistakes encountered, and how to correct them; and 4) compare and distinguish potential benefits of suturing technologies and devices used in laparoscopy.

Course Outline 12:30 Welcome, Introductions and Course Overview N.S. Moawad 12:35 Pre-‐Test (3 minutes) All Faculty 12:50 Handling Suture and Needle, Intra-‐Corporeal Knot Tying N.S. Moawad 1:05 LAB I: Drills, Needle Loading, Intra-‐Corporeal Knot Tying All Faculty 1:35 Improve Efficiency and Avoid Errors N.S. Moawad 1:50 LAB II: Continuous Suturing, Advanced Skills All Faculty 2:20 Questions & Answers All Faculty 2:30 Break 2:45 Extra-‐Corporeal Knot Tying J.H. Kim 2:55 LAB III: Extra-‐Corporeal Knot Tying All Faculty 3:20 Suture Types and Characteristics; Suturing Devices J.H. Kim 3:35 Post-‐Test All Faculty 3:50 LAB IV: Troubleshooting, Supra-‐Pubic Approach, Barbed Suture and Suturing Devices All Faculty 4:20 Questions & Answers All Faculty 4:30 Adjourn

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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor* Kimberly A. Kho* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathon Solnik* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Blue Endo, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical William M. Burke* Rosanne M. Kho* Ted T.M. Lee Consultant: Ethicon Endo-‐Surgery Javier F. Magrina* Ceana H. Nezhat Consultant: Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Other: Stock Ownership: Titan Medical Robert K. Zurawin Consultant: Bayer Healthcare Corp., CONMED Corporation, Ethicon Endo-‐Surgery, Hologic, Intuitive Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Krisztina I. Bajzak Speakers Bureau: Activis Mandi L. Beman* Amy N. Broach Consultant: Covidien Lydia Garcia* Susan Khalil* Jin Hee (Jeannie) Kim* Nash S. Moawad* Jessica M.B. Ritch* Kimberly A. Swan Other: Stock Ownership: Johnson & Johnson Mireille Truong* Bich-‐Van T. Tran* Johnny Yi* Asterisk (*) denotes no financial relationships to disclose.

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Laparoscopic suturing

SUTR-701

Handling Suture and Needle, Intra-Corporeal Knot Tying

Nash S. Moawad, MD, MSUniversity of Florida MIGS

Disclosure

I have no financial relationships to disclose.

Objectives

• 1) Explain how to overcome the obstacles to laparoscopic suturing and knot tying in relation to depth perception and port placement

• 2) Recognize the benefits and applications of laparoscopic suturing

• 3) Reproduce efficient techniques for laparoscopic tissue re-approximation and suture management

• 4) Recognize and perform efficient ipsilateral intra-corporeal knot tying

Why suture laparoscopically?

• Enabler – allows you to do more• e.g., TLH, Myomectomy, Sacro-colpopexy, USLS, etc.

• Decrease complications • e.g., bleeding, vaginal cuff dehiscence, granulation tissue,

dyspareunia, uterine rupture, avoid thermal damage, etc.

• Repair complications – decrease need for conversion.• Bowel, bladder and ureter repair.

• Refine your surgery – e.g., ovarian cystectomy, oophoropexy, bowel suspension, ventrosuspension, etc.

Laparoscopic Suturing Applications

• Video examples:• Myomectomy closure• Vaginal cuff• Ovarian cystectomy closure• Ovarian suspension • Bowel suspension • Ovarian Transposition• Bladder repair• Bowel over sewing• Suturing the uterine vessels• SCP• Ventrosuspension

Myomectomy

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Hysterectomy Bladder excision

Ventrosuspension Ovarian Transposition

Box Trainer – Dry lab

• Importance of practice

• Warm-up

• Retention with continued practice

• Simple – Cardboard box, webcam

Schools

• Ipsilateral approach

• Supra-pubic approach

• Contra-lateral approach

• Intra-corporeal knot-tying

• Extra-corporeal knot-tying

Page 5

Instruments

• Needle Holder

• Needle Grasper

• +/- Knot Pusher (Slider)

• Scissors

Intra-corporeal

• Ipsilateral approach• Where do you stand?

• Ideal for suturing

• Limitations?

Fundamentals

• Strategy: Port setup• Trocars (12 mm or backload through 5 or 3 mm trocar)

• Needle introduction (properly load outside) • Needle handling (Swivel) • Needle loading• Throwing a stitch • Knot-tying

Fundamentals

Anatomy of the needle Needle Introduction

Page 6

Needle Handling (Swivel) Video on needle handling

Needle Loading

PERF

ECT

IT!!

Fundamentals

• Pierce perpendicular to the tissue

• Utilize your “other” hand

• Stabilize target tissue

• Don’t force it

• Follow the curve of the needle (wrist rotation)

• Use the tip of the needle holder

• 1/3 + 2/3

• Instrument shaft perpendicular to needle plain

• Video on Smiley suturing and knot-tying, intracorporeal – dry lab

Page 7

•Loading is everything! •Perfect it!

References

• Einarsson, et al. Minimally Invasive Hysterectomies, A Survey on Attitudes and Barriers among Practicing Gynecologists. JMIG, Vol17, No 2, March/April 2010

• Cronin, et al. Vaginal cuff dehiscence: risk factors and management. AJOG Vol 206, Issue 4, April 2012

• Parker et al. Risk Factors for Uterine Rupture after Laparoscopic Myomectomy. JMIG, Vol 17, No 5, September/October 2010

• McCluney AL, et al. FLS simulator performance predicts intraoperative laparoscopic skill. Surg Endosc. 2007; 21(11):1991–1995.

References

• Gauger PG, et al. Laparoscopic simulation training with proficiency targets improves practice and performance of novice surgeons. Am J Surg. 2010;199(1):72–80.

• Hur H, et al. Fundamentals of Laparoscopic Surgery: A Surgical Skills Assessment Tool in Gynecology. JSLS (2011)15:21–26

• Fasolino et al. Laparoscopic Suturing: A Comparison between Controlateral Laparoscopic Suturing Technique and Ipsilateral Suturing Technique in Ob&Gyn Residents Training. Comfort, Ease, Preference, Timing, JMIG Vol 19, Issue 6, November–December, 2012

• Soper NJ, et al. FLS SAGES Manual, Volume 1; Basic Laparoscopy and Endoscopy. 3rd edition, 2012. Springer

LAB I

• Continuous loop video of intra-corporeal knot-tying during LAB I

Page 8

SUTR-701

Continuous suturing, advanced skills and troubleshooting

Nash S. Moawad, MD, MSUniversity of Florida MIGS


1) Recognize and perform efficient supra-pubic intra-corporeal knot tying

2) Recognize techniques and applications of advanced laparoscopic suturing

3) Recognize common errors in laparoscopic suturing and how to overcome them

Versatile for all pelvic procedures Ergonomics..

Needle loading & suturing: Drape Use the “other” hand Pierce perpendicular Follow the curve of the needle

Video

Page 9

Required skill for continuous running sutures Efficiency: can use same long suture for

multiple interrupted sutures.Decrease needle-in & -out exchanges Cost ? Safety ( number of needles to account for)

Video

2-layer closure – Efficient closure of vaginal cuff, hysterotomy, cystotomy & enterotomy repair.

Suture length is critical Assistant role

Video

For large bites on tension e.g. MyomectomyHemostatic e.g. Uterine artery ligation Lift! e.g. Burch, USLS, Ventrosuspension

Video Examples

Page 10

Poor outside load – Point A loading Too far, too close (use 1 inch)

2-D view zoom in 3 D Air knot – too far away Suture break – too far away

Poor loading angle Poor control Forcing the tissue – needle swinging efficiency

Pulling on the free end elongation Premature Wrist rotation – skimming through

the tissues Cuff dehiscence!!

Short loopSuture too long – use ExpertMoving 2 hands together – moving target.Free end – Too long or too shortBow tieUnnecessary hand motion – stay close to

your target (the free end).Redeem yourself – when things get out of

control back to the basics; A, B,C

Anticipate potential problems Avoid errorsMaximize efficiencyMaximize safety Teach effectively

Troubleshooting videos

Einarsson, et al. Minimally Invasive Hysterectomies, A Survey on Attitudes and Barriers among Practicing Gynecologists. JMIG, Vol 17, No 2, March/April 2010

Cronin, et al. Vaginal cuff dehiscence: risk factors and management. AJOG Vol 206, Issue 4, April 2012

Parker et al. Risk Factors for Uterine Rupture after Laparoscopic Myomectomy. JMIG, Vol 17, No 5, September/October 2010

McCluney AL, et al. FLS simulator performance predicts intraoperative laparoscopic skill. Surg Endosc. 2007; 21(11):1991–1995.

Gauger PG, et al. Laparoscopic simulation training with proficiency targets improves practice and performance of novice surgeons. Am J Surg. 2010;199(1):72–80

Hur H, et al. Fundamentals of Laparoscopic Surgery: A Surgical Skills Assessment Tool in Gynecology. JSLS (2011)15:21–26

Fasolino et al. Laparoscopic Suturing: A Comparison between Controlateral Laparoscopic Suturing Technique and Ipsilateral Suturing Technique in Ob&Gyn Residents Training. Comfort, Ease, Preference, Timing, JMIG Vol 19, Issue 6, Supplement, November–December, 2012

Soper NJ, et al. FLS SAGES Manual, Volume 1; Basic Laparoscopy and Endoscopy. 3rd edition, 2012. Springer

Page 11

Lab: Practice Expert, continuous and Cinch.Defer suprapubic practice to the last lab.

Page 12

Extra-corporeal Suturing

Jin Hee (Jeannie) Kim, MDAssistant Clinical Professor

Division of Gynecologic Specialized SurgeryDepartment of Obstetrics and Gynecology

Columbia University Medical Center / New York –Presbyterian Hospital

Disclosures


Objectives

Recognize the benefits and applications of extra-corporeal suturing

Reproduce efficient techniques of extra-corporeal suturing using the closed and open knot pusher

Learn to maximize efficiency with the multi-knot technique

Discuss extracorporeal suture assist devices including endoloop and endoknot

Benefits of Extracorporeal Suturing

An alternative to intracorporeal suturing

May be easier to perform and teach More feasible and reproducible

Less need for needle management

Actual knot is made outside the body

Depending on operator, may be a faster method

Lukong CS. Surgical techniques of laparoscopic inguinal hernia repair in childhood. Journal of Surgical Technique. 4(1): 2012; 1-5.

Downside of extracorporeal suturing

Requires long sutures

There is still a learning curve

5

Knot pushers

6

OpenClosed

Page 13

Steps for CLOSED knot pusher

Bring out needle through SAME trocar

Perform surgical knot; surgeon’s knot

Feed exit strand through knot pusher and place a hemostat at tip

Use knot pusher to drive knot ‘past point’

Perform one handed knot in opposite direction and drive knot down

7

Steps for OPEN knot pusher

Bring out needle through SAME trocar

Place hemostat on one end

Perform surgical knot

Place open knot pusher next to the knot on the exit strand and place a hemostat at tip

Use knot pusher to drive knot ‘past point’

Perform one handed knot in opposite direction and drive knot down

8

Keep suture length on each side equal

Shine some indirect light to feed suture

Keep suture edge unfrayed; use sharp scissors

Especially if multifilament

Snap the tip and drop the hemostat

Gravity is your friend!

No tension in trocar

Tension past the trocar9

Tips and tricks for the ACTIVE hand

Untwist suture by twirling knot pusher around suture

The tip of the knot pusher should be 1cm away from the knot on the exit strand

NOT on the knot

Knot pusher at an angle to the sutureNEVER parallel

Push knot down ‘past point’Into the posterior cul-de-sac

10

Tips and Tricks for the PASSIVE hand

Hold two ends of suture separately in the same hand

Alternating equal tension on each end of suture as you push down

Index and middle finger

Knot pusher at an angle to the sutureNEVER parallel

Push knot down ‘past point’Into the posterior cul-de-sac

11

The Actual Knot

Can start with surgeon’s knotSlightly harder to push down knot but can be faster

Then one-handed tie with

non-dominant hand

And alternate

Remember to maintain tension on suture but don’t strangulate

12

Page 14

Multi Knot Technique Video

13

Endoloop

Ethicon

Single use

0 18” Vicryl and PDS

14

Steps for Endoloop

Introduce into trocar

Break end at assigned area

Introduce loop around tissue to be removed; assistant pulls tissue thru loop

Cinch loop tight by pulling end of suture and pushing introducer down

If needed, place second endoloop distal to the first knot

15

Endoknot

Ethicon

42” Vicryl, PDS, Ethibond

Introduce endoknot, suture, bring out through same trocar

Snap off top of plastic endoknot

Perform extracorporeal knot tying

Use built in knot pusher to drive knot home16

Thank You

Questions?

17

Page 15

Suture Types and Characteristics; Suturing

Devices

Jin Hee (Jeannie) Kim, MDAssistant Clinical Professor

Division of Gynecologic Specialized SurgeryDepartment of Obstetrics and Gynecology

Columbia University Medical Center / New York –Presbyterian Hospital

Disclosures


Objectives

Introduce alternative suture material and devices utilized in gynecologic laparoscopic surgery

Demonstrate utility of these alternatives to facilitate laparoscopic suturing

Laparoscopic suturing

Technically challenging

Diminished tactile feedback

Lack of depth perception

Tremor amplification

Limited instrument mobility

Is there a solution?

Barbed suture

Automated suturing devices

Lapro-Ty

Endoloop

3-D vision

Robot

Barbed Suture

QuillTM

FDA approved 2004

Initially used by Plastics

V LocTM

FDA approved 2009

StratafixTM

FDA approved 2012

Greenberg et al. 2008 JMIG

Page 16

QuillTM

Angiotech

Traditionally bidirectional; unidirectional

Helical pattern

Anchors every 1mm

QuillTM

Bidirectional

Monoderm

PDO

Nylon

Polypropylene

3.5, 7,10,14, 24, 30, 40, 45cm

Unidirectional

Monoderm

PDO

20, 30, 45, 60, 70cm

Suture size is determined by its OUTER diameterWhen using barbed suture, upsize by one size3-0 traditional suture = 2-0 barbed suture

9

QuillTM Suturing Video: Myomectomy Closure

17

V LocTM 90 and 180

Covidien

Unidirectional barbed suture

20 barbs/cm

Spiral configuration of barbs

V LocTM 90Similar to MonocrylAbsorbs in 90-110 days

V LocTM 180Similar to PDS, MaxonAbsorbs in 180 days

Suture lengths: 6, 9, 12, and 18 inchesSuture size: 4-0, 3-0, 2-0, 0

V LocTM 90 and 180 V-Loc and Quill

V-Loc 90 4-0, 18”

Dual angle cut

900 anchoring barbs

Quill 3-0, 18”

Single angle cut

360 anchoring barbs

12

Cutdepth

Cutdepth

Stranddepth

Stranddepth

1Gingras K, Zaruby J, Maul D. 2012. Comparison of V-Loc™ 180 wound closure device and Quill™* PDO knotless tissue-closure device for intradermal closure in a porcine in vivo model: Evaluation of biomechanical wound strength. J Biomed Mater Res Part B 2012:100B:1053–1058.

Page 17

Advantages of Barbed Suture

No knot tying required

Equally distributed tension throughout suture

Enables continuous suturing without backsliding

Provides hemostatic closure of myometrium during myomectomy

14

Barbed suture associated with significantly shorter suturing times for laparoscopic myomectomy compared to traditional sutures

11

Alessandri et al. 2010 JMIGEinarsson et al. 2011. JMIG


15

V-LocTM vs continuous suture in lsc myomectomy

N = 19

Solitary intramural fibroids 3-5 cm

12Angioli et al. 2012. IJGO

V-loc 90 Conventional PEBL 113.7 + 74.1 ml 168.6 + 75.1 ml 0.0076

Operative time (total)

51 + 18.1 min 58 + 17.8 min 0.0616

Suturing time 9.9 + 4.3 min 15.8 + 4.7 min 0.0004

16


Does barbed suture reduce the risk of vaginal cuff dehiscence?

Retrospective study N = 387, Jan 2007- Jan 2010

149 Barbed suture vs. 229 with Vicryl or Endostitch

Mean time dehiscence 45 days

Two layer closure 0-PDO Quill 14 x 14 cm

No. Dehiscence Length of follow-up (days)

Quill (149) 0 96

Vicryl or Endostitch or Monofilament suture

10 (4.2%) 281

Siedoff et al. 2011. JMIG

17

Downside of Barbed Suture

Does barbed suture increase the risk of adhesion formation?

Unidirectional barbed suture13 canine enterotomy modelNo significant difference in adhesion scores at 21 days Miller et al. 2012 J Invest Surg

Bidirectional barbed suture23 non-pregnant ewesNecropsy at 3 months12 horns (52.2%) with barbed suture-adhesions10 horns (43.5%) with Vicryl closure-adhesions

Einarsson et al. 2011 JMIG14 18


“His” pareuniaLimited data

117 TLH, 82 completed questionnaires

5 reported persistent dyspareunia (6.8%) at 6 months post-op

6 reported “his”pareunia (8.2%)

15

Einarsson et al. 2010 JSLS

Page 18

19


Case report

Bowel obstruction after TLH

0-PDO 14 x 14 cm Quill with Lapra Ty

Presented POD #30

On laparoscopy-tail of left end of barbed suture (4cm) found as cause of point of volvulus

16Donnellan et al. 2011, JMIG

20

V-LocTM Suturing Video: Vaginal Cuff Closure

18

Automated Suture Devices

RD 180TM and TK®

LSI Solutions

Single use

First used for heart valve surgery

EndostitchTM

Covidien

Single use

SILSTM stitch

Endo360°Endo Evolution

Reusable

RD 180TM and TK®

“Running Device”5 or 10 mm

Straight or angled shaft

“Titanium Knot”Trims suture

Secures suture

Permanent clips

RD 180TM and TK® Video EndostitchTM

10 mm

Shuttle needle

Option articulating tipSILS Stitch Articulating

Suturing Device

Intracorporeal knot tying 18 cm

Extracorporeal knot tying 120 cm

Page 19

Benefits of the EndostitchTM

Needle is preloaded

Needle is protected from surrounding tissue

No needle management issues with loading or unloading

Simplifies suturing and knot tying

25

EndostitchTM

Comparative study of pyeloplasties and bladder neck suspension

Automated intracorporeal suturing versus conventional suturing

23

Endostitch Conventional P

Stitch placement 43 + 27 sec 151 + 24 sec <0.0001

Knot tying 74 + 50 sec 197 + 70 sec <0.0001

Adams et al. 1995. Urology

EndostitchTM with Barbed Suture

0, 2-0, 3-0 V-Loc

10,15,20 cm lengths

25

EndostitchTM Video

Endo360°

Reusable

Curved needle

Articulating

Roticulating

3 lengths Bariatric/single incision

Standard

Urogyn/natural orifice

Suturing into a flat plane29

Endo 360 Video

30

Page 20

Suture ComparisonSuture Name, Size Type Absorption Rate Tensile

Strength

Quill Polydioxanone Monofilament Complete by 180 days 80% at 14 days80% at 28 days

V Loc V-LocTM 90V-LocTM 180

Monofilament Complete 90-110 daysComplete by 180 days

75% at 14 days65% at 21 days

RD 180 Strongsorb 2-0Monoglide 2-0, 0

MultifilamentMonofilament

Complete 60-110 daysComplete < 110 days

49% at 21 days77% at 21 days

Endostitch Polysorb 3-0, 2-0, 0

Multifilament Complete 56-70 days 30% at 21 days

Endo360 PolydioxanonePGA Monoswift

MonofilamentMultifilamentMonofilament

Complete by 180 daysComplete 56-70 daysComplete <110 days

80% at 28 days30% at 21 days77% at 21 daysi

Cost $$$

Quill $20-60

V-Loc V-Loc 90 $20V-Loc 180 $23

RD 180 + TK RD 180 $175 eachTK Device $150 each53” suture $32 eachTi Knot clips $35 pack of 12

Endostitch Device $140-150Suture $20-28V-Loc Suture $57

Thank You

33

Page 21

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

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http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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